8/11/2019 Jama Intern Med 2014 Aug 174(8) 4 Antibiotic
1/2
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LESSIS MORE
AntibioticOveruse and Clostridium difficile
A TeachableMoment
Story FromtheFront LinesA woman in her 80s with a history of
diabetes melli-
tus and a recent arm laceration presented to the
emergency department with 1 day of fever, confusion,
and a painful, rapidly spreading erythematous area on
her arm. Because a necrotizing infection was sus-
pected, treatment with imipenem, clindamycin phos-
phate, and vancomycin hydrochloride was started.
Surgical exploration and debridement confirmed a
diagnosis of necrotizing fasciitis. Afterward, she
became hypotensive and was admitted to the inten-
sive care unit (ICU). Several operative cultures were
positive for group AStreptococcus. The patient under-
went 2 additional debridements that week and then
was transferred out of the ICU. Treatment with imi-
penem, clindamycin, and vancomycin was continued
for a total of 21 days while she remained in the hospi-
tal because of delirium.
One day after antibiotics were stopped, the
patient developed fever and profuse watery diarrhea.
Oral vancomycin and intravenous metronidazole was
started, and stool testing returned positive forClos-
tridium difficile. The next day, her diarrhea worsened,
she became hypotensive, and laboratory test results
showed profound leukocytosis, lactic acidosis, and
renal failure. She was transferred to the ICU and
required intubation, mechanical ventilation, and the
initiation of vasopressors. Abdominal imaging wasconsistent with
toxic megacolon. Colectomy was rec-
ommended, but her family declined further surgery
and the patient soon died.
TeachableMoment
This case illustrates the fulminant and potentially fatal
nature of severeC difficileinfection (CDI).Clostridium
difficilewas first recognized as the principal cause of
antibiotic-associated colitis in the late 1970s1,2; since
then, the incidence and severity of CDI in the United
States have been rising.3,4 Antibiotic exposure, par-
ticularly to broad-spectrum antibiotics and to pro-
longed durations of therapy, has been identified asthe major
risk factor for CDI.3-6 To help control rising
CDI rates, the Infectious Diseases Society of America
and the Society for Healthcare Epidemiology of
America have recommended minimizing the use of
antibiotics and limiting durations of therapy when
possible.4 Several studies have demonstrated that
when hospitals restrict the use of high-risk antibiotics,
the incidence of CDI declines.4
Inthiscase,thepatientreceivedbroad-spectruman-
tibioticsfor 3 weeks,presumably because of the sever-
ityof herinfection. However, a shorter courseof treat-
mentwith a morefocusedantibiotic regimen may have
been more appropriate.
Necrotizing fasciitis is a destructive, rapidly pro-
gressive soft-tissue infection that requires urgent sur-
gical intervention in addition to antibiotic therapy. It is
classically described as being either polymicrobial or
caused by a single pathogen, which is often group A
Streptococcus. Initial treatment with broad-spectrum
antibiotics is the standard of care; however, if a caus-
ative organism is identified, the antibiotic regimen
may be reconsidered. Infectious Diseases Society of
America guidelines suggest treating group A strepto-
coccal necrotizing fasciitis with a combination of intra-
venous penicillin and clindamycin and continuing
treatment until no further debridements are required,
the patients condition is clinically improved, and the
patient has been afebrile for 2 to3 days.7 According to
these guidelines, the patient described could have
been treated with penicillin and clindamycin for
approximately 1 week.It is impossible to infer whether the
patient would
have developed CDI if she had been treated with a
shorter, narrow-spectrum antibiotic course. The rec-
ommended antibiotic regimen would still have
included clindamycin, which is strongly associated
with CDI.3,5,6 In addition, CDI has been reported after
only brief courses of antibiotics as well as in patients
who received no antibiotics.4 The patients advanced
age and her prolonged hospital stay were also inde-
pendent risk factors for CDI.3-5 Nonetheless, her risk
of developing CDI may have been lower had her anti-
biotic exposure been reduced.
Thiscase demonstratesthat using lengthy coursesof
broad-spectrumantibiotics maybe harmful and that
sometimesthe best possible treatmentmay be to limit
or stop antibiotic therapy.
Published Online: June16, 2014.
doi:10.1001/jamainternmed.2014.2299.
Conflict of Interest Disclosures: Nonereported.
1. LarsonHE, PriceAB. Pseudomembranouscolitis:
presence of clostridial toxin. Lancet. 1977;2(8052-
8053):1312-1314.
2. Bartlett JG,ChangTW,GurwithM, GorbachSL,
OnderdonkAB. Antibiotic-associated
pseudomembranouscolitis due to toxin-producing
clostridia. NEngl JMed. 1978;298(10):531-534.
3. Bartlett JG. Narrative review: the newepidemic
ofClostridiumdifficileassociatedenteric disease.
Ann Intern Med. 2006;145(10):758-764.
4. CohenSH, Gerding DN,JohnsonS, etal; Society
for HealthcareEpidemiologyof America; Infectious
Diseases Society of America. Clinical practice
PERSPECTIVE
Timothy Sullivan,MDDivisionof Infectious
Diseases, IcahnSchool
of Medicineat Mount
Sinai,New York,
New York.
Corresponding
Author: Timothy
Sullivan, MD,Division
of InfectiousDiseases,
IcahnSchoolof
Medicine at Mount
Sinai,One Gustave L.
Levy Place,PO Box
1090,New York,NY
10029(timothy
.sullivan@mountsinai
.org).
Opinion
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